Conscious Sedation Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
Date
Designated Person to Pick You Up From Appt.
We will call them close to the end of your procedure to arrange for pick up.
Name
First Name
Last Name
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Conscious Sedation
I understand that the purpose of conscious sedation is to more comfortably receive necessary care. Conscious sedation is not required to provide the necessary dental care. I understand that conscious sedation has limitations and risks and absolute success cannot be guaranteed.
Yes
No
I understand that conscious sedation is a drug-induced state of reduced awareness and decreased ability to respond. Conscious sedation is not sleep. I will be able to respond during the procedure. My ability to respond normally returns when the effects of the sedative wear off.
Yes
No
I understand that my conscious sedation will be achieved oral administration approximately 1 hour before my appointment.
Yes
No
I understand that the alternatives to conscious sedation are:
No sedation: The necessary procedure is performed under local anesthetic with the patient fully aware.
Anxiolytics: Taking a pill to reduce fear and anxiety.
Nitrous oxide sedation: Commonly called laughing gas, nitrous oxide provides relaxation but the patient is still generally aware of surrounding activities. Its effects can be reversed in five minutes with oxygen.
Intravenous Administration: The doctor could inject the sedative in a tube connected to a vein in my arm.
General Anesthetic: Commonly called deep sedation, a patient under general anesthetic has no awareness and must have their breathing temporarily supported. General anesthesia is more appropriate for longer procedures lasting 3 or more hours.
What is your preferred pharmacy to sent a prescription for sedation medication?
If yes, then please specify it on the field above.
Are you currently taking any medications?
If yes, then please specify it on the field above.
Do you have any questions regarding your upcoming appointment?
If yes, then please specify it on the field above.
Acknowledgement and Waiver
I allow and authorize Yeo Family Dental Group to perform this procedure to me. The doctor explained the nature of the treatment and how it will help me.
I allow Yeo Family Dental Group to administer anesthesia and understands the side effects of the medications given to me.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I understand that I am not allowed to eat or drink anything but water the day of the procedure unless discussed with prior to appointment with Dr. Yeo
I acknowledge that all information I provided int his form is true and accurate.
Patient/Parent/Guardian Signature
Signed Date
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Month
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Day
Year
Date
Submit
Submit
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